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Rheumatoid Arthritis — SCE Rheumatology MCQ

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ModerateRheumatologyRheumatoid ArthritisSCE Rheumatology

A 36-year-old adult has newly diagnosed active rheumatoid arthritis. They are rheumatoid factor and anti-CCP positive, have early marginal erosions and have a DAS28-CRP of 4.9. Baseline full blood count, renal function and liver tests are satisfactory, and there is no contraindication to methotrexate. Which is the most appropriate initial disease-modifying treatment strategy?

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Correct answer: B — Start oral methotrexate and escalate within a treat-to-target strategy

Oral methotrexate monotherapy, promptly initiated and escalated within a treat-to-target programme, is the best option. NICE recommends oral methotrexate, leflunomide or sulfasalazine as first-line cDMARD monotherapy for newly diagnosed active rheumatoid arthritis; among the listed options, methotrexate is the appropriate anchor drug. Disease activity should be monitored and treatment adjusted towards remission or low disease activity. Hydroxychloroquine monotherapy is more appropriate for mild or palindromic disease, not seropositive erosive disease. Glucocorticoids may be used briefly as bridging treatment but not as long-term monotherapy. NSAIDs provide symptomatic relief without adequate disease modification. A TNF inhibitor is not normally started before an adequate conventional DMARD strategy has been attempted.

Reference: National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management (NG100), sections 1.2.1 and 1.4.1–1.4.3. Updated 2020; surveillance reviewed 2024. https://www.nice.org.uk/guidance/ng100/chapter/Recommendations